Fulwood Hall Hospital

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

We looked for evidence that safety was a priority for everyone, and leaders embedded a culture of openness and collaboration. Leaders had systems for identifying and responding to deteriorating patients on the ward and in theatres. People received treatment and care to reduce the risk of avoidable harm. There was safety processes arranged before surgical procedures started, with staff working together to ensure the right patient had the correct procedure. Patients were safe from neglect, abuse and discrimination. Patient’s gave informed consent prior to procedures. However, processes for the management of medicine were not always followed.

At our last assessment we rated this key question requires improvement. At this assessment, the rating has changed to good.

We have not awarded this service a score for Safe.

Find out about when we will not publish a key question score and what we look at when we assess Safe.

The service had a proactive and positive culture of safety, based on openness and honesty. Staff and leaders listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice. Learning was shared with staff.

The service managed patient safety incidents well. Managers investigated incidents and shared lessons learned with the whole team and the wider service. Managers ensured actions from patient safety alerts were addressed and progress was monitored.

Daily meetings which were attended by teams across the surgical departments discussed patient safety alerts and learning from incidents was shared. Daily email bulletins were circulated to share learning to the immediate teams and the wider service.

There was a current incident reporting policy which included the investigation and management of incidents. This policy reflected the provider guidance, such as Ramsay Severity Rating (RQR) and national guidance, such as the Patient Safety Incident Response Framework (PSIRF).

Incidents were reported onto an electronic incident reporting system for managing incidents. Staff we spoke to understood what type of incidents and near misses should be reported and they knew how to report them. The provider used the electronic incident reporting system to analysis incidents to detect themes and trends. We were told of ongoing work by the provider to further improve how information is used to improve analysis of incidents.

Managers provided feedback to staff following investigations of incidents and staff was informed of changes being made because of learning from incidents. Managers and staff told us that debriefs are carried out after serious incidents and support is offered to staff.

There had been no reported never events in the 12 months prior to the inspection. Never Events are serious, preventable safety incidents which should not occur if the available preventative measures are followed.

Staff understood the duty of candour. Duty of candour is a legal obligation of healthcare providers and professionals to be open and honest with patients when things have gone wrong. There was duty of candour information displayed within staff only areas and the provider had a current duty of candour policy. We were provided with examples of when staff had applied duty of candour.

Examples of how learning from incidents and complaints had taken place were provided.

The service worked with patients and healthcare partners to establish and maintain safe systems of care, in which safety was monitored and managed. Staff made sure there was continuity of care, including when responsibility for patient care moved between different areas of a service and between providers.

The service provided elective surgery to NHS and privately funding patients. Patients could access the service through GP referral or their healthcare insurer.

Safety and continuity of care was a priority throughout patients care pathway. Patients were assessed prior to surgery and findings considered when planning care and treatment. There was admission criteria for all patients accessing elective surgery at the hospital. These criteria were used to determine if patients were suitable for surgery.

The service is considered a level zero site which means that it only offers elective surgery to patients that can be cared for at ward level and are not assessed as being at risk of deterioration. In the event of an emergency the service had a policy for recognition and management of the deteriorating patient. In the 12 months prior to inspection there had been 28 patients transferred to local NHS Hospitals for more specialist care.

In the records that we reviewed we found that the surgical safety checklists were carried out in accordance with recognised best practice.

At the last inspection intra-operative temperatures were not being recorded consistently and it was reported that the provider should improve the recording of intra-operative temperature checks. Audit documentation reviewed for the 12 months prior to inspection indicated low compliance for intra-operative temperature recording. The service had implemented an action plan in October 2025 to improve compliance.

At this inspection we observed intra-operative temperature was being recorded correctly. We reviewed 10 patient records which indicated that intra-operative temperatures had been recorded correctly for all these patients. The November 2025 audit for intra-operative temperature recording indicated appropriate intra-operative temperature recording for all patients.

There were systems and processes to ensure the correct patients were treated throughout the patient journey. We tracked patient care from admission onto the ward to the operating theatre. We observed handover of patient information including all related identification checking processes. Once in theatre, the World Health Organisation (WHO) surgical safety check list was used to avoid harm. We observed completion of the process.

The last inspection found that the provider did not always carry out surgical safety checklists in accordance with recognised best practice to ensure the safety of the patient during surgical episodes. The provider was told that they must ensure that World Health Organisation (WHO) checklists are undertaken fully and correctly, according to guidelines, before and after every surgical episode.

The transfer of patients from the operating theatre to the recovery was managed safely. Suitably skilled and qualified staff accompanied patients in all areas.

When overall responsibility for the care and treatment of a patient moved to a different service provider, such as transfer to the NHS, there was communication processes in place which enabled the transfer.

The service worked with patients and healthcare partners where required, to understand how best to keep people safe, what it meant for individuals and the best way to achieve that. Staff concentrated on protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The service shared concerns quickly and appropriately.

It was a mandatory requirement for staff to complete safeguarding training. Compliance was 67% of theatre staff and 70% of ward staff for adult safeguarding level 3 and 98% of theatre staff and 100% of ward staff for adults safeguarding level 2. For children’s safeguarding compliance was 100% for level 2. All heads of departments were trained to level 3 and staff had access to level 4 trained staff to support training, supervision and incidents.

Safeguarding leads for the service were available to support staff with safeguarding concerns. Each day the safeguarding lead would be named in the daily team meetings. All staff we spoke with were able to name the safeguarding leads and knew how to contact them.

The provider had a current safeguarding policy which reflected national guidance. Staff understood how to protect patients from abuse and the service worked well with other agencies to do so. Staff were able to give us specific examples of when they have identified patients and relatives at risk and what steps they took to protect them within the safeguarding framework.

The provider had policies in place for safeguarding adults and children at the risk of abuse or neglect.

The service worked with patients to understand and manage risks by thinking holistically. Staff provided care to meet patient’s needs which was safe, supportive, and enabled patient to do the things that mattered to them.

Patients that were referred to the hospital for surgery were assessed during pre-operative assessment appointments. The assessment process identified patients with specific requirements, such as a patient living with a diagnosis of dementia or a patient with caring commitments.

Prior to a patient’s admission for surgery multi-disciplinary meetings were held to discuss and plan care of patients with specific needs. We observed a multi-disciplinary team meeting planning and saw how a patient’s needs were met by the care plan including that they should be cared for in an observable room close to the nurse’s station. There was, consideration given to the time of surgery and there were additional staff on duty to support the patient safely.

We spoke to patients during our inspection who told us they felt listened to, risks had been explained, and they were involved in decisions about their care and treatment. For example, a patient told us that the anaesthetist and the surgeon had spoken to them individually to discuss risks specific to them and to support them to make decisions about their care.

The service did not always detect and control potential risks in the care environment. Leaders and staff did not always make sure equipment, facilities and technology supported the delivery of safe care or that there was appropriate mitigation of the risk.

Patients and visitors entered the hospital via the main reception where they were greeted by staff and escorted to the ward. Some areas of the hospital were restricted to members of staff accessible only by swipe card, such as rooms where medicines and medical records were kept.

The environment of the ward and other areas used for patient care reduced the risk of patient harm. Flooring was appropriate in most areas visited, except for some of the theatre flooring that was awaiting replacement. This had been included in the hospitals risk register.

Fire safety equipment was available and had been serviced. Fire exits were clear and free from obstruction.

Patients could reach call bells. Call bells were positioned by patient beds, and staff showed patients how to use them to summon help.

Staff disposed of clinical waste safely, both inside and outside the building. Waste was segregated and labelled in accordance with the providers policy. The risk of sharps injuries was minimised because of the safe management of sharp implements.

The provider followed the protocols for safe water in healthcare. Low use taps were flushed in accordance with guidance relating to legionella and appropriate water testing was carried out, including testing for legionella.

Specialist equipment used in the operating theatres was used in accordance with national guidance and regulatory requirements. An equipment maintenance program was in place for medical devices.

The service did not always make sure there were enough qualified, skilled and experienced staff. Staff did not always make sure staff received effective support, supervision and development. They did not always work together well to provide safe care that met patient’s individual needs.

Ward managers used a safer staffing tool to ensure adequate numbers of staff with the appropriate skill mixes for the number of patients and the type of surgery expected. Managers had the ability to make changes to the staffing levels to meet changing demands.

Between December 2024 and November 2025 there was an average sickness rate of 4.5%. Between December 2024 and December 2025 there was an average turnover of staff of 10%. Any shortfalls in staffing on the wards were filled with bank or agency staff. All theatre staff were permanently employed staff, and no agency staff were used in the theatres.

All new starters received an induction. There was a provider training matrix for mandatory requirements. This included a combination of face to face and electronic training modules that were role specific such as infection, prevention and control, adult resuscitation, moving and handling, aseptic non touch technique (ANTT), the Oliver McGowan training on learning disability and autism, care and communication of the deteriorating patient, information governance, conflict resolution, dementia awareness and safeguarding.

Overall compliance with mandatory training for E-learning modules was 98% and the compliance for face-to-face training for theatre staff was 94% and ward staff 85%. All individual modules were greater than 94%. All staff, substantive and agency staff, were required to complete an appraisal and were up to date.

Nursing staff were supported by other clinical staff that included surgeons who carried out the operations and the resident doctor (RD).

We reviewed recruitment files for 5 staff members and found that these were completed with the necessary documents required prior to on boarding with the organisation. Medical staff were employed following a practising privileges policy.

Staff had to meet competency requirements specific to their role. All levels of theatre staff had met 100% of the competency requirements. However, the competency levels for ward staff ranged from 40% for wound care to 95% for blood transfusion.

The service did not always assess or manage the risk of infection. Staff did not always detect and control the risk of it spreading. There were examples of poor practice which increased the risk to patients.

All areas and equipment we inspected looked visibly clean and well maintained. Theatres were observed to be compliant with national guidance.

Hand-washing facilities and personal protective equipment (PPE) were available in all areas including hand sanitisers.

There was a provider Infection Prevention Control (IPC) policy which included guidance for staff. The policy review period was every 3 years. The review date of November 2026 had been extended by 3 months, which meant the policy was within the extension period at the time of our inspection.

There were 18 surgical site infections reported in the 12 months prior to inspection and were investigated. All confirmed infections were subject to Patient Safety Investigation Framework process.

The provider reported incidents of surgical site infections following hip and knee arthroplasty and spinal surgery in line with national guidelines for surveillance. The provider had a service level agreement with a Consultant Microbiologist, and a trained tissue viability nurse was based on the ward for specialist support and advice on wound care.

Infection Prevention and Control audits were completed and where compliance was below targets action plans were implemented. At the time of our inspection ongoing actions were in place for wound care management, infection prevention and control governance and assurance, and peri-operative warming.

Hand hygiene audits were carried out monthly. The audit for the hand hygiene compliance of theatre staff was 86% in November 2025. We observed some shortfalls of hand hygiene techniques in the theatre department which was fed back to the theatre manager at the time and immediate action was taken to address the issues.

The service did not always make sure that medicines and treatments were safe and met patient’s needs, capacities and preferences. Staff did not always involve patient in planning.

The provider used systems and processes to prescribe, administer, record and store medicines. There was a Medicines Policy and a provider Medicines Optimisation Framework in place which included the management of controlled drugs.

The management of medicines in theatre met the appropriate standards and controlled drugs cupboard was secure and documentation completed correctly.

However, there was shortfalls in the management of controlled drugs at ward level. We found incomplete documentation of the controlled drugs order books. Controlled drugs had been ordered and dispensed without the required staff authorised to do so.

There had been controlled drugs which were unaccounted for which had not been reported to the Care Quality Commission at the time of our inspection.

Audits for medicines management were completed over the previous 12 months. However, the administration of medicines was not on the services risk register.

At the time of the inspection, we escalated our concerns to senior leaders who addressed this immediately.